NCLEX Review - Flashcard Style

B All of these patient goals may be appropriate for the patient, but the only goal that directly addresses her body image disturbance is "the patient will demonstrate by diet control and skin care, increased interest in control of acne."

A 16-year-old patient has been diagnosed with Body Image Disturbance related to severe acne. In planning nursing care, what is an appropriate goal for this patient? A - The patient will make above-B grades in all tests at school. B - The patient will demonstrate, by diet control and skin care, increased interest in control of acne. C - The patient reports that she feels more self-confident in her music and art, which she enjoys. D - The patient expresses that she is very smart in school.

C This patient's self-concept disturbance is mainly one of devaluing herself and thinking that she is no good. This is a Self-Esteem Disturbance.

A 33-year-old businessperson is in counseling, attempting to deal with a long-repressed history of sexual abuse by her father. "I guess I should feel satisfied with what I've achieved in life, but I'm never content, and nothing I achieve makes me feel good about myself.... I hate my father for making me feel like I'm no good. This is an awful way to live." What self-concept disturbance is this person experiencing? A - Personal Identity Disturbance B - Body Image Disturbance C - Self-Esteem Disturbance D - Altered Role Performance

D The traumatic nature of this patient's injuries, her fiancé's failure to contact her, and her withdrawal response all point to potential problems with both body image and self-esteem. It is not true that self-esteem needs are of low priority.

A 36-year-old woman enters the emergency department with severe burns and cuts on her face after an auto accident in a car driven by her fiancé of 3 months. Three weeks later, her fiancé has not yet contacted her. The patient states that she is very busy and she is too tired to have visitors anyway. The patient frequently lies with her eyes closed and head turned away. What do these data suggest? A - There is no disturbance in self-concept. B - This patient has ego strength and high self-esteem but may have a disturbance of body image. C - The area of self-esteem has very low priority at this time and should be ignored until much later. D - It is probable that there are disturbances in self-esteem and body image.

"National safety goals seek prevention of injury."

A client asks the nurse if the staff members make many mistakes because there are so many posters and signs about safety on the walls. Which response by the nurse is most appropriate? "We want the public to know we are trying to be safe." "Clinic staff members require frequent reminders about client safety." "National safety goals focus on the individual making the error." "National safety goals seek prevention of injury."

It validates nursing care, not medical care.

A client in the clinic is being asked to participate in a research study. The client asks why a nursing research study is necessary because research on this subject has already been published by the American Medical Association (AMA). Which goal of nursing research will the nurse share with this client regarding the goal of nursing research? It supports the medical profession. It validates nursing through medical research. It supports products used in nursing care. It validates nursing care, not medical care.

Notify the primary healthcare provider.

A client in the intensive care unit is combative and pulling at the endotracheal tube, which must remain in place. After applying soft hand restraints to protect the client's airway, which action should the nurse take next? Notify the primary healthcare provider. Notify the family of the need for restraints. Reassess the need for the restraints in 8 hours. Document the application of restraints in the chart.

B This patient's concern is with body image. The information provided does not suggest a nursing diagnosis of Personal Identity Disturbance, Self-Esteem Disturbance, or Altered Role Performance.

A college freshman away from home for the first time says to a counselor, "Why did I have to be born into a family of big bottoms and short fat legs! No one will ever ask me out for a date. Oh, why can't I have long thin legs like everyone else in my class? What a frump I am." What type of disturbance in self-concept is this patient experiencing? A - Personal Identity Disturbance B - Body Image Disturbance C - Self-Esteem Disturbance D - Altered Role Performance

Poor health in an unfavorable environment

A group of nurses has volunteered to go on a health mission to rural Haiti. The majority of the people the nurses will be working with do not have access to health care and live in poverty. Based on this data, which level of wellness do the nurses anticipate when providing care during this mission trip? An emergent high level of wellness in an unfavorable environment Protected poor health in an unfavorable environment Poor health in an unfavorable environment Protected poor health in a favorable environment

e Nonmaleficence is defined as the obligation to prevent harm. Autonomy is respect for another's right to make decisions, beneficence obligates us to benefit the patient, justice obligates us to act fairly, and fidelity obligates us to keep our promises.

A home health nurse performs a careful safety assessment of the home of a frail older adult to prevent harm to the patient. The nurse's action reflects which principle of bioethics? A - Autonomy B - Beneficence C - Justice D - Fidelity E - Nonmaleficence

a The principle of autonomy obligates nurses to provide the information and support patients and their surrogates need to make decisions that advance their interests. Acting with justice means giving each person his or her due, acting with fidelity involves keeping promises to patients, and acting with nonmaleficence means avoiding doing harm to patients.

A hospice nurse is caring for a patient with end-stage cancer. What action demonstrates this nurse's commitment to the principle of autonomy? A - The nurse helps the patient prepare a durable power of attorney document. B - The nurse gives the patient undivided attention when listening to concerns. C - The nurse keeps a promise to provide a counselor for the patient. D - The nurse competently administers pain medication to the patient.

C The first intervention priority with a mother who feels incompetent to parent a daughter is to assist the mother to identify what is preventing her from being an effective parent and then to explore solutions aimed at improving her parenting skills. The other interventions may prove helpful, but they do not directly address the mother's problem with her feelings of incompetence.

A mother of a 10-year-old daughter tells the nurse: "I feel incompetent as a parent and don't know how to discipline my daughter." What should be the nurse's first intervention when counseling this patient? A - Recommend that she discipline her daughter more strictly and consistently. B - Make a list of things her husband can do to give her more time and help her improve her parenting skills. C - Assist the mother to identify both what she believes is preventing her success and what she can do to improve. D - Explore with the mother what the daughter can do to improve her behavior and make the mother's role as a parent easier.

d Nurses are legally responsible for carrying out the orders of the health care provider in charge of a patient unless an order would lead a reasonable person to anticipate injury if it was carried out. If the nurse should have anticipated injury and did not, both the prescribing health care provider and the administering nurse are responsible for the harms to which they contributed.

A nurse administers the wrong medication to a patient and the patient is harmed. The health care provider who ordered the medication did not read the documentation that the patient was allergic to the drug. Which statement is true regarding liability for the administration of the wrong medication? A - The nurse is not responsible, because the nurse was following the doctor's orders. B - Only the nurse is responsible, because the nurse actually administered the medication. C - Only the health care provider is responsible, because the health care provider actually ordered the drug. D - Both the nurse and the health care provider are responsible for their respective actions.

b, c, e Incident reports are used for quality improvement and should not be used for disciplinary action against staff members. They are a means of identifying risks and are filled out by the nurse responsible for the injured party. An incident report makes facts available in case litigation occurs; in some states, incident reports may be used in court as evidence. A health care provider completes the incident form with documentation of the medical examination of the patient, employee, or visitor with an actual or potential injury. Documentation in the patient record should not include the fact that an incident report was filed.

A nurse answers a patient's call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed and then fills out an incident report. Which statements accurately describe steps of this procedure and why it is performed? Select all that apply. A - An incident report is used as disciplinary action against staff members. B - An incident report is used as a means of identifying risks. C - An incident report is used for quality control. D - The facility manager completes the incident report. E - An incident report makes facts available in case litigation occurs. F - Filing of an incident report should be documented in the patient record.

B The patient's inability to list more than three items about himself indicates deficient self-knowledge. There are not enough data provided to determine whether he lacks self-esteem, has unrealistic self-expectations, or is unable to evaluate himself.

A nurse asks a 25-year-old patient to describe himself with a list of 20 words. After 15 minutes, the patient listed "25 years old, male, named Joe," then declared he couldn't think of anything else. What should the nurse document regarding this patient? A - Lack of self-esteem B - Deficient self-knowledge C - Unrealistic self-expectation D - Inability to evaluate himself

D The nurse can obtain a quick indication of a patient's self-esteem by using a graphic description of self-esteem as the discrepancy between the "real self" (what we think we really are) and the "ideal self" (what we think we would like to be). The nurse would have the patient plot two points on a line—real self and ideal self (Fig. 41-5). The greater the discrepancy, the lower the self-esteem; the smaller the discrepancy, the higher the self-esteem.

A nurse asks a patient who has few descriptors of his self to list facts, traits, or qualities that he would like to be descriptive of himself. The patient quickly lists 25 traits, all of which are characteristic of a successful man. When asked if he knows anyone like this, he replies, "My father; I wish I was like him." What does the discrepancy between the patient's description of himself as he is and as he would like to be indicate? A - Negative self-concept B - Modesty (lack of conceit) C - Body image disturbance D - Low self-esteem

D Afebrile means without fever. Therefore the temperature assessed is within the normal range for an adult. The nurse does not need to perform any other actions based on this finding.

A nurse assesses an oral temperature for an adult patient and records that the patient is "afebrile." What would be the nurse's best response to this finding? A - Check the patient record for prescribed antipyretic medication. B - Report the finding to the primary care provider. C - Take the patient temperature using a different method. D - No action is necessary; this is a normal reading.

b Allowing the patient to "dangle" on the edge of the bed prior to rising might prevent orthostatic hypotension. Arising and moving about slowly, especially after a period of bed rest, might also prevent orthostatic hypotension. If a patient becomes dizzy or feels faint, the nurse should return the patient to bed and place in a supine position, which restores blood flow to the brain. A beta blocker is given to decrease blood pressure for a patient with hypertension. There are several medications that raise blood pressure and are used to treat orthostatic hypotension.

A nurse assesses orthostatic hypotension in an older adult. What would be an appropriate intervention for this patient? A - Encourage the patient to rise from a sitting position quickly to improve blood flow. B - Allow the patient to "dangle" for a few minutes prior to rising to a standing position. C - If the patient feels faint or dizzy, return the patient to bed and place in Fowler's position. D - Administer a beta-adrenergic blocker to increase blood pressure.

b An emollient soothes dry skin, whereas frequent bathing increases dryness, as does alcohol. Discouraging fluid intake leads to dehydration and, subsequently, dry skin.

A nurse assisting with a patient bed bath observes that an older female adult has dry skin. The patient states that her skin is always "itchy." Which nursing action would be the nurse's best response? A - Bathe the patient more frequently. B - Use an emollient on the dry skin. C - Massage the skin with alcohol. D - Discourage fluid intake.

a, c, e, f Native Americans, Alaska Natives, Hispanics, and Whites are more prone to developing diabetes mellitus. African Americans are prone to hypertension, stroke, sickle cell anemia, lactose intolerance, and keloids. Asians are prone to hypertension, liver cancer, thalassemia, and lactose intolerance.

A nurse caring for culturally diverse patients in a health care provider's office is aware that patients of certain cultures are more prone to specific disease states than the general population. Which patients would the nurse screen for diabetes mellitus based on the patient's race? Select all that apply. A - A Native American patient B - An African-American patient C - An Alaska Native D - An Asian patient E - A White patient F - A Hispanic patient

a, b, c Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of aspiration pneumonia and other systemic diseases. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition.

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply. A - It promotes the patient's sense of well-being. B - It prevents deterioration of the oral cavity. C - It contributes to decreased incidence of aspiration pneumonia. D - It eliminates the need for flossing. E - It decreases oropharyngeal secretions. F - It helps to compensate for an inadequate diet.

b, c, d, f Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity.

A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk? Select all that apply. A - A patient who is taking antibiotics for chronic bronchitis B - A patient diagnosed with type II diabetes C - A patient who is obese D - A patient who has a nervous habit of biting his nails E - A patient diagnosed with prostate cancer F - A patient whose job involves frequent handwashing

b The American Association of Colleges of Nursing lists promoting universal access to health care as an example of social justice. Providing honest information and documenting care accurately and honestly are examples of integrity, and planning care in partnership with patients is an example of autonomy.

A nurse caring for patients in an institutional setting expresses a commitment to social justice. What action best exemplifies this attribute? A - Providing honest information to patients and the public B - Promoting universal access to health care C - Planning care in partnership with patients D - Documenting care accurately and honestly

b, c, d A value is a belief about the worth of something, about what matters, which acts as a standard to guide one's behavior. A value system is an organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. A person's values influence beliefs about human needs, health, and illness; the practice of health behaviors; and human responses to illness. Values guide the practice of nursing care. An individual is not born with values; rather, values are formed during a lifetime from information from the environment, family, and culture.

A nurse caring for patients in the intensive care unit develops values from experience to form a personal code of ethics. Which statements best describe this process? Select all that apply. People are born with values. A - Values act as standards to guide behavior. B - Values are ranked on a continuum of importance. C - Values influence beliefs about health and illness. D - Value systems are not related to personal codes of conduct. E - Nurses should not let their values influence patient care.

c The person or government bringing suit against another is called the plaintiff. Appellates are courts of law, defendants are the ones being accused of a crime or tort, and attorneys are the lawyers representing both the plaintiff and defendant.

A nurse in a NICU fails to monitor a premature newborn according to the protocols in place, and is charged with malpractice. What is the term for those bringing the charges against the nurse? A - Appellates B - Defendants C - Plaintiffs D - Attorneys

d The American Association of Colleges of Nursing defines integrity as acting in accordance with an appropriate code of ethics and accepted standards of practice. Altruism is a concern for the welfare and well-being of others. Autonomy is the right to self-determination, and human dignity is respect for the inherent worth and uniqueness of individuals and populations.

A nurse incorporates the "five values that epitomize the caring professional nurse" (identified by the American Association of Colleges of Nursing) into a home health care nursing practice. Which attribute is best described as acting in accordance with an appropriate code of ethics and accepted standards of practice? A - Altruism B - Autonomy C - Human dignity D - Integrity

c, e, f Nursing is recognized increasingly as a profession based on the following defining criteria: well-defined body of specific and unique knowledge, strong service orientation, recognized authority by a professional group, code of ethics, professional organization that sets standards, ongoing research, and autonomy and self-regulation.

A nurse instructor outlines the criteria establishing nursing as a profession. What teaching point correctly describes this criteria? Select all that apply. A - Nursing is composed of a well-defined body of general knowledge B - Nursing interventions are dependent upon medical practice C - Nursing is a recognized authority by a professional group D - Nursing is regulated by the medical industry E - Nursing has a code of ethics F - Nursing is influenced by ongoing research

A high level of wellness in a favorable environment

A nurse is assessing a client to determine the level of wellness. The client practices yoga for relaxation several times a week follows a nutritionally sound diet and has a supportive, sound relationship with a spouse and several children. Based on this data, which does this client exemplify? An emergent high level of wellness in an unfavorable environment. A high level of wellness in a favorable environment Protected poor health in a favorable environment. An emergent high level of wellness in a favorable environment

a, d, e, f The normal temperature range for infants is 37.1° to 38.1°C (98.7° to 100.5°F). The normal pulse rate for an adolescent is 55 to 105. The normal respiratory rate for an adult is 12 to 20 breaths/min and the normal pulse for an older adult is 40 to 100 beats/min. The normal blood pressure for a toddler is 89/46 and the normal temperature for a child is 36.8° to 37.8°C

A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a vital sign within normal limits? Select all that apply. A - A 4-month-old infant whose temperature is 38.1°C (100.5°F) B - A 3-year-old whose blood pressure is 118/80 C - A 9-year-old whose temperature is 39°C (102.2°F) D - An adolescent whose pulse rate is 70 beats/min E - An adult whose respiratory rate is 20 breaths/min F - A 72-year-old whose pulse rate is 42 beats/min

b The science of nursing is the knowledge base for care that is provided. In contrast, the skilled application of that knowledge is the art of nursing. Providing holistic care to patients based on the science of nursing is considered the art of nursing.

A nurse is caring for a patient in the ICU who is being monitored for a possible cerebral aneurysm following a loss of consciousness in the emergency department (ED). The nurse anticipates preparing the patient for ordered diagnostic tests. What aspect of nursing does this nurse's knowledge of the diagnostic procedures reflect? A - The art of nursing B - The science of nursing C - The caring aspect of nursing D - The holistic approach to nursing

d The priority risk factor in this situation is the possibility of an infection developing in the open skin area. The other risk factors may be potential problems for this patient and may also require nursing interventions after the first diagnosis is addressed.

A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What risk factor would be a priority concern for the nurse when caring for this patient? A - Imbalanced nutrition B - Impaired physical mobility C - Chronic pain D - Infection

a, c, d, f It is recommended to use an alcohol-based handrub in the following situations: before direct contact with patients; after direct contact with patient skin; after contact with body fluids if hands are not visibly soiled; after removing gloves; before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement; before donning sterile gloves prior to an invasive procedure; if moving from a contaminated body site to a clean body site; and after contact with objects contaminated by the patient. Keep in mind that handrubs are not appropriate for use with C. difficile infection.

A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply. A - Providing a bed bath for a patient B - Visibly soiled hands after changing the bedding of a patient C - Removing gloves when patient care is completed D - Inserting a urinary catheter for a female patient E - Assisting with a surgical placement of a cardiac stent F - Removing old magazines from a patient's table

d, e, f A person may be a member of multiple cultural, ethnic, and racial groups at one time. Culture guides what is acceptable behavior for people in a specific group. Cultural practices and beliefs may evolve over time, but they mainly remain constant as long as they satisfy a group's needs. The United States has become more (not less) inclusive of same-sex couples. The definition of cultural diversity includes, but is not limited to, people of varying cultures, racial and ethnic origin, religion, language, physical size, biological sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location. Cultural diversity, including culture, ethnicity, and race, is an integral component of both health and illness.

A nurse is caring for patients of diverse cultures in a community health care facility. Which characteristics of cultural diversity that exist in the United States should the nurse consider when planning culturally competent care? Select all that apply. A - The United States has become less inclusive of same-sex couples. B - Cultural diversity is limited to people of varying cultures and races. C - Cultural diversity is separate and distinct from health and illness. D - People may be members of multiple cultural groups at one time. E - Culture guides what is acceptable behavior for people in a specific group. F - Cultural practices may evolve over time but mainly remain constant.

A The patient's self-expectations are realistic, given his multiple commitments, and seem to be positively motivating his development.

A nurse is counseling a husband and wife who have decided that the wife will get a job so that the husband can go to pharmacy school. Their three teenagers, who were involved in the decision, are also getting jobs to buy their own clothes. The husband, who plans to work 12 to 16 hours weekly, while attending school, states, "I was always an A student, but I may have to settle for Bs now because I don't want to neglect my family." How would the nurse document the husband's self-expectations? A - Realistic and positively motivating his development B - Unrealistic and negatively motivating his development C - Unrealistic but positively motivating his development D - Realistic but negatively motivating his development

A, C, F The nurse should include the following teaching points for parents: (1) reinforce their child's positive qualities; (2) address negative qualities constructively; (3) ignore neutral behavior that is a matter of taste, preference, or personal style; (4) don't feel they have to "fix things" for their children; (5) describe the child's behavior in a nonjudgmental manner; and (6) let their child know what to expect, practice the necessary skills, be patient, and make it safe to fail.

A nurse is counseling parents attending a parent workshop on how to build self-esteem in their children. Which teaching points would the nurse include to help parents achieve this goal? Select all that apply. A - Teach the parents to reinforce their child's positive qualities. B - Teach the parents to overlook occasional negative behavior. C - Teach parents to ignore neutral behavior that is a matter of personal preference. D - Teach parents to listen and "fix things" for their children. E - Teach parents to describe the child's behavior and judge it. F - Teach parents to let their children practice skills and make it safe to fail.

c The systolic pressure is 120 mm Hg. The diastolic pressure is 80 mm Hg, the lowest pressure present on arterial walls when the heart rests between beats. The difference between the systolic and diastolic pressures is called the pulse pressure. The rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction is the pulse.

A nurse is documenting a blood pressure of 120/80 mm Hg. The nurse interprets the 120 to represent: A - the rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction. B - the lowest pressure present on arterial walls while the ventricles relax. C - the highest pressure present on arterial walls while the ventricles contract. D - the difference between the pressure on arterial walls with ventricular contraction and relaxation.

c If an impervious gown has been tied in front of the body at the waist, the nurse should untie the waist strings before removing gloves. Gloves are always removed first because they are most likely to be contaminated, followed by the goggles, gown, and mask, and hands should be washed thoroughly after the equipment has been removed and before leaving the room.

A nurse is finished with patient care. How would the nurse remove PPE when leaving the room? A - Remove gown, goggles, mask, gloves, and exit the room B - Remove gloves, perform hand hygiene, then remove gown, mask, and goggles C - Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene D - Remove goggles, mask, gloves, and gown, and perform hand hygiene

c According to the principles of medical asepsis, the nurse should move equipment away from the body when brushing, scrubbing, or dusting articles to prevent contaminated particles from settling on the hair, face, or uniform. The nurse should carry soiled items away from the body to prevent them from touching the clothing. The nurse should not put soiled items on the floor, as it is highly contaminated. The nurse should also clean the least soiled areas first and then move to the more soiled ones to prevent having the cleaner areas soiled by the dirtier areas.

A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? A - The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air B - The nurse places soiled bed linens and hospital gowns on the floor when making the bed C - The nurse moves the patient table away from the nurse's body when wiping it off after a meal D - The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items

c Asking patients what types of foods they eat for meals is culturally sensitive. The other questions are culturally insensitive.

A nurse is interviewing a newly admitted patient. Which question is considered culturally sensitive? A - "Do you think you will be able to eat the food we have here?" B - "Do you understand that we can't prepare special meals?" C - "What types of food do you eat for meals?" D - "Why can't you just eat our food while you are here?"

C The data point to the patient having a positive self-concept ("I'm a good helper") and fairly high self-esteem (realizes his strengths and limitations). The statement "But I'm not very smart" is accurate and is not an indication of a negative self-concept.

A nurse is performing a psychological assessment of a 19-year-old patient who has Down's syndrome. The patient is mildly developmentally disabled with an intelligence quotient of 82. He told his nurse, "I'm a good helper. You see I can carry these trays because I'm so strong. But I'm not very smart, so I have just learned to help with the things I know how to do." What findings for self-concept and self-esteem would the nurse document for this patient? A - Negative self-concept and low self-esteem B - Negative self-concept and high self-esteem C - Positive self-concept and fairly high self-esteem D - Positive self-concept and low self-esteem

b, c, e, f Proper hand hygiene includes removing jewelry (with the exception of a plain wedding band), wetting the hands and wrist area with the hands lower than the elbows, using about one teaspoon of liquid soap, using friction motion for at least 20 seconds, washing to 1 in above the wrists with a friction motion for at least 20 seconds, and rinsing thoroughly with water flowing toward fingertips.

A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly? Select all that apply. A - Removes all jewelry including a platinum wedding band B - Washes hands to 1 in above the wrists C - Uses approximately one teaspoon of liquid soap D - Keeps hands higher than elbows when placing under faucet E - Uses friction motion when washing for at least 20 seconds F - Rinses thoroughly with water flowing toward fingertips

A, C, D When assisting the patient to maintain a positive sense of self, the nurse should address the patient by name when entering the room; perform care in a manner that respects the patient's privacy; offer a simple explanation before moving the patient's body in any way; acknowledge the patient's status, role, and individuality; and converse with the patient about the patient's life experiences.

A nurse is performing patient care for a severely ill patient who has cancer. Which nursing interventions are likely to assist this patient to maintain a positive sense of self? Select all that apply. A - The nurse makes a point to address the patient by name upon entering the room. B - The nurse avoids fatiguing the patient by performing all procedures in silence. C - The nurse performs care in a manner that respects the patient's privacy and sensibilities. D - The nurse offers the patient a simple explanation before moving her in any way. E - The nurse ignores negative feelings from the patient since they are part of the grieving process. F - The nurse avoids conversing with the patient about her life, family, and occupation.

d A master's degree (MSN) prepares advanced practice nurses. Many master's graduates gain national certification in their specialty area, for example, as family nurse practitioners (FNPs) or nurse midwives.

A nurse is practicing as a nurse-midwife in a busy OB-GYN office. Which degree in nursing is necessary to practice at this level? A - LPN B - ADN C - BSN D - MSN

c If the patient touches a sterile field, the nurse should discard the supplies and prepare a new sterile field. If the patient is confused, the nurse should have someone assist by holding the patient's hand and reinforcing what is happening.

A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation? A - Ask another nurse to hold the hand of the patient and continue setting up the field B - Remove the instrument that was touched by the patient and continue setting up the sterile field C - Discard the supplies and prepare a new sterile field with another person holding the patient's hand D - No action is necessary since the patient has touched his or her own sterile field

b Bathing practices and cleansing habits and rituals vary widely. The patient's preferences should always be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patient's personal hygiene. The availability of staff to assist may be important, but the patient's preferences are a higher priority.

A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when planning a patient's personal hygiene? A - When the patient had his or her most recent bath B - The patient's usual hygiene practices and preferences C - Where the bathing fits in the nurse's schedule D - The time that is convenient for the patient care assistant

Social

A nurse is teaching a group of couples a class on building positive relationships at a local community center. The nurse is focusing this session on learning skills to be open-minded and respectful to those with opposing opinions. Based on this data, on which component of wellness is the nurse focusing this session? Physical Social Environment Emotional

c In all aspects of nursing, it is important to treat each patient as an individual. This is also true in providing culturally competent care. This basic objective can be accomplished by learning the predominant language in the community, researching the patient's culture, and recognizing the influence of family on the patient's life.

A nurse is teaching a novice nurse how to provide care for patients in a culturally diverse community health clinic. Although all these actions are recommended, which one is MOST basic to providing culturally competent care? A - Learning the predominant language of the community B - Obtaining significant information about the community C - Treating each patient at the clinic as an individual D - Recognizing the importance of the patient's family

a The nurse is trying to impose her belief that bassinets are preferable to baby slings on the African mother—in spite of the fact that African women have safely carried babies in these slings for years.

A nurse is telling a new mother from Africa that she shouldn't carry her baby in a sling created from a large rectangular cloth. The African woman tells the nurse that everyone in Mozambique carries babies this way. The nurse believes that bassinets are safer for infants. This nurse is displaying what cultural bias? A - Cultural imposition B - Clustering C - Cultural competency D - Stereotyping

b When using PPE, the nurse should work from "clean" areas to "dirty" ones, put on PPE before entering the patient room, always use goggles instead of personal glasses, and remove PPE in the doorway or anteroom just before exiting.

A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care? A - The nurse puts on PPE after entering the patient room B - The nurse works from "clean" areas to "dirty" areas during bath C - The nurse personalizes the care by substituting glasses for goggles D - The nurse removes PPE after the bath to talk with the patient in the room

b The ESFT model guides providers in understanding a patient's explanatory model (a patient's conception of her or his illness), social and environmental factors, and fears and concerns, and also guides providers in contracting for therapeutic approaches. Asking the questions: "How does having COPD affect your lifestyle?" explores the explanatory model, "How do you get your medications?" refers to the social and environmental factor, "Are you concerned about the side effects of your medications?" addresses fears and concerns, and "Can you describe how you will take your medications?" involves therapeutic contracting.

A nurse is using the ESFT model to understand a patient's conception of a diagnosis of chronic obstructive pulmonary disease (COPD). Which interview question would be MOST appropriate to assess the E aspect of this model—Explanatory model of health and illness? A - How do you get your medications? B - How does having COPD affect your lifestyle? C - Are you concerned about the side effects of your medications? D - Can you describe how you will take your medications?

Clean the environment of clutter.

A nurse manager is assessing the hospital environment in order to decrease the risk for client falls. Which is the best intervention to decrease the risk of client falls? Keep the call button within reach at all times. Read label directions Keep electrical cords under the bed. Clean the environment of clutter.

a A blood pressure cuff that is not the right size may cause an incorrect reading. It will not cause serious injury to the patient, but a small amount of pressure may be felt on the arm from a too tight cuff. It will not cause the loss of Korotkoff sounds.

A nurse notices a student is taking a blood pressure measurement on a patient with a cuff that is too large. What should be the nurse's response to the student? A - If you use the wrong cuff you will get an incorrect reading. B - If you use the wrong cuff you will cause injury to the patient. C - If you use the wrong cuff you will cause dangerous pressure on the arm. D - If you use the wrong cuff you will cause the loss of Korotkoff sounds.

c Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area. Nursing is one of the groups operating under state laws that promote the general welfare by determining minimum standards of education through accreditation of schools of nursing. Licensure is a legal document that permits a person to offer to the public skills and knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license. State board of approval ensures that nurses have received the proper training to practice nursing.

A nurse pleads guilty to a misdemeanor negligence charge for failing to monitor a patient's vital signs during routine eye surgery, leading to the death of the patient. The nurse's attorney explained in court that the nurse was granted recognition in a specialty area of nursing. What is the term for this type of credential? A - Accreditation B - Licensure C - Certification D - Board approval

A Based simply on the facts given, the 55-year-old news reporter would be least likely to experience body image or role performance disturbance because she is beyond her childbearing years, and the hysterectomy should not impair her ability to report the news. The young clergyperson's inability to preach, the 32 year old's massive myocardial infarction, and the model's breast resection have much greater potential to result in self-concept problems.

A nurse practicing in a health care provider's office assesses self-concept in patients during the patient interview. Which patient is least likely to develop problems related to self-concept? A = A 55-year-old television news reporter undergoing a hysterectomy (removal of uterus) B - A young clergyperson whose vocal cords are paralyzed after a motorbike accident C - A 32-year-old accountant who survives a massive heart attack D - A 23-year-old model who just learned that she has breast cancer

c, d, e The ANA Social Policy Statement (2010) describes the social context of nursing, a definition of nursing, the knowledge base for nursing practice, the scope of nursing practice, standards of professional nursing practice, and the regulation of professional nursing.

A nurse practicing in a primary care center uses the ANA's Nursing's Social Policy Statement as a guideline for practice. Which purposes of nursing are outlined in this document? Select all that apply. A - A description of the nurse as a dependent caregiver B - The provision of standards for nursing educational programs C - A definition of the scope of nursing practice D - The establishment of a knowledge base for nursing practice E - A description of nursing's social responsibility F - The regulation of nursing research

d Stereotyping is assuming that all members of a group are alike. This is not an example of cultural competence nor is the nurse imposing her culture on the patient. Clustering is not an applicable concept.

A nurse states, "That patient is 78 years old—too old to learn how to change a dressing." What is the nurse demonstrating? A - Cultural imposition B - Clustering C - Cultural competency D - Stereotyping

b In the home setting, where the patient's environment is more controlled, medical asepsis is usually recommended, with the exception of self-injection. This is the appropriate procedure for the home and is not a personal preference or a negligent action.

A nurse teaches a patient at home to use clean technique when changing a wound dressing. What would be a consideration when preparing this teaching plan? A - It is the personal preference of the nurse whether or not to use clean technique B - The use of clean technique is safe for the home setting C - Surgical asepsis is the only safe method to use in a home setting D - It is grossly negligent to recommend clean technique for changing a wound dressing

b Ethical distress results from knowing the right thing to do but finding it almost impossible to execute because of institutional or other constraints (in this case, the nurse fears the loss of job). Ethical uncertainty results from feeling troubled by a situation but not knowing if it is an ethical problem. Ethical dilemmas occur when the principles of bioethics justify two or more conflicting courses of action. Ethical residue is what nurses experience when they seriously compromise themselves or allow themselves to be compromised.

A nurse wants to call an ethics consult to clarify treatment goals for a patient no longer able to speak for himself. The nurse believes his dying is being prolonged painfully. The patient's doctor threatens the nurse with firing if the nurse raises questions about the patient's care or calls the consult. What ethical conflict is this nurse experiencing? A - Ethical uncertainty B - Ethical distress C - Ethical dilemma D - Ethical residue

d To add a sterile solution to a sterile field, the nurse would open the solution container according to directions and place the cap on the table away from the field with the edges up. The nurse would then hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 in (10 to 15 cm).

A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task? A - Place the bottle cap on the table with the edges down B - Hold the bottle inside the edge of the sterile field C - Hold the bottle with the label side opposite the palm of the hand D - Pour the solution from a height of 4 to 6 in (10 to 15 cm)

b When a needlestick injury occurs, the nurse should wash the exposed area immediately with warm water and soap, report the incident to the appropriate person and complete an incident injury report, consent to and await the results of blood tests, consent to PEP, and attend counseling sessions regarding safe practice to protect self and others.

A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when administering the patient's medications. What would be the first action of the nurse following the exposure? A - Report the incident to the appropriate person and file an incident report B - Wash the exposed area with warm water and soap C - Consent to PEP at appropriate time D - Set up counseling sessions regarding safe practice to protect self

b, f Prizing something one values involves pride, happiness, and public affirmation, such as losing weight or running a marathon. When choosing, one chooses freely from alternatives after careful consideration of the consequences of each alternative, such as quitting smoking and working fewer hours. Finally, the person who values something acts on the value by combining choice and behavior with consistency and regularity, such as joining a gym for the year and following a low-cholesterol diet faithfully.

A nurse who is working in a hospital setting uses value clarification to help understand the values that motivate patient behavior. Which examples denote "prizing" in the process of values clarification? Select all that apply. A - A patient decides to quit smoking following a diagnosis of lung cancer. B - A patient shows off a new outfit that she is wearing after losing 20 pounds. C - A patient chooses to work fewer hours following a stress-related myocardial infarction. D - A patient incorporates a new low-cholesterol diet into his daily routine. E - A patient joins a gym and schedules classes throughout the year. F - A patient proudly displays his certificate for completing a marathon.

a, b, c Activities to restore health focus on the person with an illness and range from early detection of a disease to rehabilitation and teaching during recovery. These activities include drug counseling, teaching patients how to administer their medications, and performing range-of-motion exercises for bedridden patients. Recommending a yoga class for stress reduction is a goal of preventing illness, and teaching a nutrition class is a goal of promoting health. A hospice care nurse helps to facilitate coping with disability and death.

A nurse working in a rehabilitation facility focuses on the goal of restoring health for patients. Which examples of nursing interventions reflect this goal? Select all that apply. A - A nurse counsels adolescents in a drug rehabilitation program B - A nurse performs range-of-motion exercises for a patient on bedrest C - A nurse shows a diabetic patient how to inject insulin D - A nurse recommends a yoga class for a busy executive E - A nurse provides hospice care for a patient with end-stage cancer F - A nurse teaches a nutrition class at a local high school

"Clients at risk for skin breakdown should be repositioned every 2 hours."

A nursing instructor assigns a literature review on evidence-based practice (EBP) to a group of students. Which statement demonstrates that the students understand the benefits of EBP? "This project will allow me to teach other students about literature searches" "Clients at risk for skin breakdown should be repositioned every 2 hours." "Literature searches allow nurses to find problems to implement EBP." "I will be able to present a paper about skin assessment from my query."

b Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. Student nurses are responsible for their own acts of negligence if these result in patient injury. A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital-controlled program because the student is considered an employee of the hospital. Nursing instructors may share responsibility for damages in the event of patient injury if an assignment called for clinical skills beyond a student's competency or the instructor failed to provide reasonable and prudent clinical supervision. Most nursing programs require students to carry personal professional liability insurance.

A nursing student asks the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true? A - Students are not responsible for their acts of negligence resulting in patient injury. B - Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. C - Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor. D - Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary.

a A single blood pressure reading that is mildly elevated is not significant, but the measurement should be taken again over time to determine if hypertension is a problem. The nurse would recommend a return visit to the clinic for a recheck.

A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient? A - Follow-up measurements of blood pressure B - Immediate treatment by a health care provider C - No action, because the nurse considers this reading is due to anxiety D - A change in dietary intake

b The blood pressure should be taken in the arm opposite the one with the infusion.

A patient has intravenous fluids infusing in the right arm. How should the nurse obtain the blood pressure on this patient? A - Take the blood pressure in the right arm. B - Take the blood pressure in the left arm. C - Use the smallest possible cuff. D - Report inability to take the blood pressure.

b Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm greater room for expansion and facilitating lung expansion.

A patient is experiencing dyspnea. What is the nurse's priority action? A - Remove pillows from under the head. B - Elevate the head of the bed. C - Elevate the foot of the bed. D - Take the blood pressure.

a, e The pulse often increases when a person is experiencing pain. Pain does not affect body temperature and may increase (not decrease) blood pressure. Acute pain may increase respiratory rate but decrease respiratory depth.

A patient reports severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply. A - An increase in the pulse rate B - A decrease in body temperature C - A decrease in blood pressure D - An increase in respiratory depth E - An increase in respiratory rate F - An increase in body temperature

A An unfamiliar culture, coupled with traumatic life events and loss of husband and job, result in this patient's total loss of her sense of self: "I don't know who I am supposed to be here." Her very sense of identity is at stake, not merely her body image, self-esteem, or role performance.

A patient who has been in the United States only 3 months has recently suffered the loss of her husband and job. She states that nothing feels familiar—"I don't know who I am supposed to be here"—and says that she "misses home terribly." For what alteration in self-concept is this patient most at risk? A - Personal Identity Disturbance B - Body Image Disturbance C - Self-Esteem Disturbance D - Altered Role Performance

d When rewarding and punishing are used to transmit values, children are rewarded for demonstrating values held by parents and punished for demonstrating unacceptable values. Through modeling, children learn what is of high or low value by observing parents, peers, and significant others. Children whose caregivers use the moralizing mode of value transmission are taught a complete value system by parents or an institution (e.g., church or school) that allows little opportunity for them to weigh different values. Those who use the laissez-faire approach to value transmission leave children to explore values on their own (no single set of values is presented as best for all) and to develop a personal value system.

A pediatric nurse is assessing a 5-year-old boy who has dietary modifications related to his diabetes. His parents tell the nurse that they want him to value good nutritional habits, so they decide to deprive him of a favorite TV program when he becomes angry after they deny him foods not on his diet. This is an example of what mode of value transmission? A - Modeling B - Moralizing C - Laissez-faire D - Rewarding and punishing

b During the prodromal stage, the person has vague signs and symptoms, such as fatigue and a low-grade fever. There are no obvious symptoms of infection during the incubation period, and they are more specific during the full stage of illness before disappearing by the convalescent period.

A school nurse is performing an assessment of a student who states, "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection? A - Incubation period B - Prodromal stage C - Full stage of illness D - Convalescent period

C Each option with the exception of c correctly addresses some aspect of fostering healthy development in children. Because children need effective structure and development, giving them total freedom to do as they please may actually hinder their development.

A school nurse is teaching parents how to foster a healthy development of self in their children. Which statement made by one of the parents needs to be followed up with further teaching? A - "I love my child so much I 'hug him to death' every day." B - "I think children need challenges, don't you?" C - "My husband and I both grew up in very restrictive families. We want our children to be free to do whatever they want." D - "My husband and I have different ideas about discipline, but we're talking this out because we know it's important for Johnny that we be consistent."

D Important roles for this patient are being a student and a friend. His illness is preventing him from doing either of these well. This self-concept disturbance is basically one that concerns role performance.

A sophomore in high school has missed a lot of school this year because of leukemia. He said he feels like he is falling behind in everything, and misses "hanging out at the mall" with his friends most of all. For what disturbance in self-concept is this patient at risk? A - Personal Identity Disturbance B - Body Image Disturbance C - Self-Esteem Disturbance D - Altered Role Performance

d Criminal law concerns state and federal criminal statutes, which define criminal actions such as murder, manslaughter, criminal negligence, theft, and illegal possession of drugs. Public law regulates relationships between people and the government. Private or civil law includes laws relating to contracts, ownership of property, and the practice of nursing, medicine, pharmacy, and dentistry.

A state attorney decides to charge a nurse with manslaughter for allegedly administering a lethal medication. This is an example of what type of law? A - Public law B - Private law C - Civil law D - Criminal law

a, c, f Advocacy is the protection and support of another's rights. Among the patients with special advocacy needs are the very young and the older adult, those who are seriously ill, and those with disabilities; this is not a comprehensive list. Effective advocacy may entail becoming politically active. Patient advocacy is the responsibility of every member of the professional caregiving team—not just nurses. Nurse advocates do not make health care decisions for their patients and residents. Instead, they facilitate patient decision making. Advocacy does not entail supporting patients in all their preferences.

A student nurse begins a clinical rotation in a long-term care facility and quickly realizes that certain residents have unmet needs. The student wants to advocate for these residents. Which statements accurately describe this concept? Select all that apply. A - Advocacy is the protection and support of another's rights. B - Patient advocacy is primarily performed by nurses. C - Patients with special advocacy needs include the very young and the older adult, those who are seriously ill, and those with disabilities. D - Nurse advocates make good health care decisions for patients and residents. E - Nurse advocates do whatever patients and residents want. F - Effective advocacy may entail becoming politically active.

d Liability involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages. Duty refers to an obligation to use due care (what a reasonably prudent nurse would do) and is defined by the standard of care appropriate for the nurse-patient relationship. Breach of duty is the failure to meet the standard of care. Causation, the most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) actually caused the injury. Damages are the actual harm or injury resulting to the patient.

A veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient hernia surgery. The nurse admitted failing to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, stating that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. What criteria must be established to prove that the nurse is guilty of malpractice or negligence in this case? A - The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. B - The fact that this patient should not have died since she was a healthy grandmother of 10, who was physically active and involved in her community. C - The nurse intended to harm the patient and was willfully negligent, as evidenced by the tragic outcome of routine hernia surgery. D - The nurse had a duty to monitor the patient's vital signs, and due to the nurse's failure to perform this duty in this circumstance, the patient died.

b The nurse should ask an interpreter for help. Many facilities have a qualified interpreter who understands the health care system and can reliably provide assistance. Using short words, talking loudly, and providing instructions in writing will not help the nurse communicate with this patient. Explaining why care can't be provided is not an acceptable choice because the nurse is required to provide care; also, since the patient doesn't speak English, she won't understand what the nurse is saying.

A young Hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish and the nurse speaks only English. What is the appropriate nursing intervention? A - Use short words and talk more loudly. B - Ask an interpreter for help. C - Explain why care can't be provided. D - Provide instructions in writing.

b The National Advisory Council on Nurse Education and Practice identifies the following critical challenges to nursing practice in the 21st century: A growing population of hospitalized patients who are older and more acutely ill, increasing health care costs, and the need to stay current with rapid advances in medical knowledge and technology.

According to the National Advisory Council on Nurse Education and Practice, what is a current health care trend contributing to 21st century challenges to nursing practice? A - Decreased numbers of hospitalized patients B - Older and more acutely ill patients C - Decreasing health care costs owing to managed care D - Slowed advances in medical knowledge and technology

a The nurse should not discuss the case with anyone at the facility (with the exception of the risk manager), with the plaintiff, with the plaintiff's lawyer, with anyone testifying for the plaintiff, or with reporters. This is one of the cardinal rules for nurse defendants.

An attorney is representing a patient's family who is suing a nurse for wrongful death. The attorney calls the nurse and asks to talk about the case to obtain a better understanding of the nurse's actions. How should the nurse respond? A - "I'm sorry, but I can't talk with you; you will have to contact my attorney." B - "I will answer your questions so you'll understand how the situation occurred. C - "I hope I won't be blamed for the death because it was so busy that day." D - "First tell me why you are doing this to me. This could ruin my career!"

a The ability to be ethical, to make decisions, and to act in an ethically justified manner begins in childhood and develops gradually.

An older nurse asks a younger coworker why the new generation of nurses just aren't ethical anymore. Which reply reflects the BEST understanding of moral development? A - "Behaving ethically develops gradually from childhood; maybe my generation doesn't value this enough to develop an ethical code." B - "I don't agree that nurses were more ethical in the past. It's a new age and the ethics are new!" C - "Ethics is genetically determined...it's like having blue or brown eyes. Maybe we're evolving out of the ethical sense your generation had." D - "I agree! It's impossible to be ethical when working in a practice setting like this!"

a, b, f Rubella, diphtheria, and adenovirus infection are illnesses transmitted by large-particle droplets and require droplet precautions in addition to standard precautions. Airborne precautions are used for patients who have infections spread through the air with small particles; for example, tuberculosis, varicella, and rubeola. Contact precautions are used for patients who are infected or colonized by a multidrug-resistant organism (MDRO), such as MRSA.

In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply. A - A patient diagnosed with rubella B - A patient diagnosed with diphtheria C - A patient diagnosed with varicella D - A patient diagnosed with tuberculosis E - A patient diagnosed with MRSA F - An infant diagnosed with adenovirus infection

a, d Cultural imposition occurs when a hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily, and when a Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. Cultural blindness occurs when a nurse treats all patients the same whether or not they come from a different culture. Culture conflict occurs when a nurse ridicules a patient by telling another nurse that Jewish diet restrictions are just a way for Jewish patients to get a special tray of their favorite foods. When a nurse refuses to respect an older adult's ability to speak for himself or herself, or if the nurse refuses to treat a patient based on that patient's sexual orientation, the nurse is engaging in stereotyping.

In order to provide culturally competent care, nurses must be alert to factors inhibiting sensitivity to diversity in the health care system. Which nursing actions are examples of cultural imposition? Select all that apply. A - A hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily. B - A nurse treats all patients the same whether or not they come from a different culture. C - A nurse tells another nurse that Jewish diet restrictions are just a way for them to get a special tray of their favorite foods. D - A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. E - A nurse directs interview questions to an older adult's daughter even though the patient is capable of answering them. F - A nurse refuses to care for a married gay man who is HIV positive because she is against same-sex marriage.

a, d Each state has a nurse practice act that protects the public by broadly defining the legal scope of nursing practice. Practicing beyond those limits makes nurses vulnerable to charges of violating the state nurse practice act. Nurse practice acts also list the violations that can result in disciplinary actions against nurses. Clinical procedures are covered by the health care institutions themselves. Medication administration and delegation are topics covered by the board of nursing. Laws governing Medicare reimbursement are enacted through federal legislation.

Newly hired nurses in a busy suburban hospital are required to read the state nurse practice act as part of their training. Which topics are covered by this act? Select all that apply. A - Violations that may result in disciplinary action B - Clinical procedures C - Medication administration D - Scope of practice E - Delegation policies F - Medicare reimbursement

a, c, f When performing a skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to report and record findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, and allow data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings.

Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. A - Compare bilateral parts for symmetry. B - Proceed in a toe-to-head systematic manner. C - Use standard terminology to report and record findings. D - Do not allow data from the nursing history to direct the assessment. E - Document only skin abnormalities on the patient record. F - Perform the appropriate skin assessment when risk factors are identified.

d Florence Nightingale elevated the status of nursing to a respected occupation, improved the quality of nursing care, and founded modern nursing education. Clara Barton established the Red Cross in the United States in 1882. Lillian Wald was the founder of public health nursing. Lavinia Dock was a nursing leader and women's rights activist instrumental in establishing women's right to vote.

Nurses today complete a nursing education program, and practice nursing that identifies the personal needs of the patient and the role of the nurse in meeting those needs. Which nursing pioneer is MOST instrumental in this birth of modern nursing? A - Clara Barton B - Lilian Wald C - Lavinia Dock D - Florence Nightingale

a During World War II, large numbers of women worked outside the home. They became more independent and assertive, which led to an increased emphasis on education. The war itself created a need for more nurses and resulted in a knowledge explosion in medicine and technology. This trend broadened the role of nurses to include practicing in a wide variety of health care settings.

Nurses today work in a wide variety of health care settings. What trend occurred during World War II that had a tremendous effect on this development in the nursing profession? A - There was a shortage of nurses and an increased emphasis on education. B - Emphasis on the war slowed development of knowledge in medicine and technology C - The role of the nurse focused on acute technical skills used in hospital settings. D - Nursing was dependent on the medical profession to define its priorities.

a Nurse practice acts are established in each state to regulate the practice of nursing by defining the legal scope of nursing practice, creating a state board of nursing to make and enforce rules and regulations, define important terms and activities in nursing, and establish criteria for the education and licensure of nurses. The acts do not determine the content covered on the NCLEX, but they do have the legal authority to allow graduates of approved schools of nursing to take the licensing examination. The acts also may determine educational requirements for licensure, but do not provide the education. Institutional policies are created by the institutions themselves.

Nursing in the United States is regulated by the state nurse practice act. What is a common element of each state's nurse practice act? A - Defining the legal scope of nursing practice B - Providing continuing education programs C - Determining the content covered in the NCLEX examination D - Creating institutional policies for health care practices

d, a, b, e, c Phase I is characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; the first tapping sound is the systolic pressure. Phase II is characterized by muffled or swishing sounds, which may temporarily disappear, especially in hypertensive people; the disappearance of the sound during the latter part of phase I and during phase II is called the auscultatory gap. Phase III is characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery. Phase IV is characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; in adults, the onset of this phase is considered to be the first diastolic pressure. Phase V is the last sound heard before a period of continuous silence; the pressure at which the last sound is heard is the second diastolic pressure.

Prioritization: Place the following descriptions of the phases of Korotkoff sounds in order from phase I to phase V. A - Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap B - Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery C - The last sound heard before a period of continuous silence, known as the second diastolic pressure D - Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; known as the systolic pressure E - Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure

b Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Battery is an assault that is carried out. Every person is granted freedom from bodily contact by another person unless consent is granted. The Fourth Amendment gives citizens the right of privacy and the right to be left alone; a nurse who disregards these rights is guilty of invasion of privacy. Unjustified retention or prevention of the movement of another person without proper consent can constitute false imprisonment.

Review of a patient's record revealed that no one obtained informed consent for the heart surgery that was performed on the patient. Which intentional tort has been committed? A - Assault B - Battery C - Invasion of privacy D - False imprisonment

c Indwelling urinary catheters have been implicated in most HAIs. Cigarette smoking, a normal white blood cell count, and a vegetarian diet have not been implicated as risk factors for HAIs.

The nurse assesses patients to determine their risk for HAIs. Which hospitalized patient would the nurse consider most at risk for developing this type of infection? A - A 60-year-old patient who smokes two packs of cigarettes daily B - A 40-year-old patient who has a white blood cell count of 6,000/mm3 C - A 65-year-old patient who has an indwelling urinary catheter in place D - A 60-year-old patient who is a vegetarian and slightly underweight

d Standard precautions apply to all patients receiving care in hospitals, regardless of their diagnosis or possible infection status. These recommendations include blood; all body fluids, secretions, and excretions except sweat; nonintact skin; and mucous membranes.

The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients? A - Only patients with diagnosed infections B - Only patients with visible blood, body fluids, or sweat C - Only patients with nonintact skin D - All patients receiving care in hospitals

d Considering the outer inch of a sterile field as contaminated is a principle of surgical asepsis. Moisture such as from splashes contaminates the sterile field, and sneezing would contaminate the sterile gloves. Forceps soaked in disinfectant are not considered sterile.

The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. Which action by the nurse is appropriate? A - Keep splashes on the sterile field to a minimum B - Cover the nose and mouth with gloved hands if a sneeze is imminent C - Use forceps soaked in a disinfectant D - Consider the outer 1 in of the sterile field as contaminated

b, c, e, f Blood pressure increases with age due to a decreased elasticity of the arteries, increasing peripheral resistance. Blood pressure is usually lowest on arising in the morning. Women usually have lower blood pressure than men until menopause occurs. Blood pressure increases after eating food. Blood pressure tends to be lower in the prone or supine position. Increased blood pressure is more prevalent and severe in African American men and women.

The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which statements accurately describe these factors? Select all that apply. A - Blood pressure decreases with age. B - Blood pressure is usually lowest on arising in the morning. C - Women usually have lower blood pressure than men until menopause. D - Blood pressure decreases after eating food. E - Blood pressure tends to be lower in the prone or supine position. F - Increased blood pressure is more prevalent in African Americans.

Risk for Injury

The nurse is caring for a client who is prone to falls. Which nursing diagnosis would be most appropriate for this client? Risk for Injury Risk for Suffocation Deficient Knowledge Risk for Disuse Syndrome

"I will be helping to validate nursing care."

The nurse is caring for a client who requires extensive wound care. The client has consented to participate in a nursing research study regarding wound care. Which client statement indicates an understanding of the goal related to the research? "This research will not influence my care." "Nursing care is based solely on research." "I will be paid to participate in the research project." "I will be helping to validate nursing care."

a When minority groups live within a dominant group, many members lose the cultural characteristics that once made them different in a process called assimilation. Cultural imposition occurs when one person believes that everyone should conform to his or her own belief system. Culture shock occurs when a person is placed in a different culture perceived as strange, and ethnocentrism is the belief that the ideas, beliefs, and practices of one's own cultural group are best, superior, or most preferred to those of other groups.

The nurse practitioner sees patients in a community clinic that is located in a predominately White neighborhood. After performing assessments on the majority of the patients visiting the clinic, the nurse notes that many of the minority groups living within the neighborhood have lost the cultural characteristics that made them different. What is the term for this process? A - Cultural assimilation B - Cultural imposition C - Culture shock D - Ethnocentrism

a, c, d, e The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal surgery. The insertion of the thermometer can slow the heart rate by stimulating the vagus nerve, thus patients post-MI should not have a rectal temperature taken. Assessing a rectal temperature is also contraindicated in patients who are neutropenic (have low white blood cell counts, such as in leukemia), in patients who have certain neurologic disorders, and in patients with low platelet counts.

The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated? Select all that apply. A - A newborn who has hypothermia B - A child who has pneumonia C - An older adult who is post MI (heart attack) D - A teenager who has leukemia E - A patient receiving erythropoietin to replace red blood cells F - An adult patient who is newly diagnosed with pancreatitis

d In early civilizations, the nurse usually was the mother who cared for her family during sickness by providing physical care and herbal remedies. This nurturing and caring role of the nurse has continued to the present. At the beginning of the 16th century, the shortage of nurses led to the recruitment of women who had committed crimes to provide nursing care instead of going to jail. In the early Christian period, women called deaconesses made the first organized visits to sick people, and members of male religious orders gave nursing care and buried the dead. The influences of Florence Nightingale were apparent from the middle of the 19th century to the 20th century; one of her accomplishments was identifying the personal needs of the patient and the nurse's role in meeting those needs.

The role of nurses in today's society was influenced by the nurse's role in early civilization. Which statement best portrays this earlier role? A - Women who committed crimes were recruited into nursing the sick in lieu of serving jail sentences. B - Nurses identified the personal needs of the patient and their role in meeting those needs. C - Women called deaconesses made the first visits to the sick, and male religious orders cared for the sick and buried the dead. D - The nurse was the mother who cared for her family during sickness by using herbal remedies.

A The difference between the apical and radial pulse rate is called the pulse deficit.

Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 beats/min. How will the nurse document this difference? A - Pulse deficit B- Pulse amplitude C - Ventricular rhythm D - Heart arrhythmia

A With convection, the heat is disseminated by motion between areas of unequal density, for example, the action of a fan blowing cool air over the body. Turning off the fan would reduce heat loss via convection. Removing the patient's ice pack is an intervention to prevent heat loss via conduction. Reducing the temperature in the room may decrease heat loss via perspiration (evaporation); increasing the temperature in the room might increase heat loss via evaporation.

Upon assessment of a patient, the nurse determines that a patient is at risk of losing body heat through the process of convection. What would be the nurse's best response? A - Turn off the overhead fan in the patient's room. B - Remove the patient's ice pack. C - Reduce the temperature in the room. D - Increase the temperature in the room.

d A rate of 140 beats/min in an adult is an abnormal pulse and should be reported to the primary care provider or the nurse in charge of the patient.

While taking an adult patient's pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next? A - Check the pulse again in 2 hours. B - Check the blood pressure. C- Record the information. D - Report the rate to the primary care provider.